ACH Payments

Name *

First

Last

Member ID *

Email *

(Receipt will be sent to this email address.)

Invoice Number *

Payment Information *

One-time Payment — I authorize VPPPA to debit my account for a one-time payment. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.
Recurring — I authorize VPPPA to debit my account on my annual renewal date for VPPPA membership payment. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the merchant in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

ACH Terms

Recourse *

I/we have certain recourse rights if any debit does not comply with this agreement. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF), I understand that the merchant may at its discretion attempt to process the charge again within 30 days, and agree to an additional $20 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment.

Name on Bank Account *

Bank Name *

ABA Routing Number *

Account Number *

Bank Account Type *

Amount Due *